28.13 Combined Psychotherapy and Pharmacotherapy
897
and shared decision making and does not portray the practitio-
ner as an authority or parental figure. When patients make what
appear to be bad choices, the practitioner must consider the
patient’s right to choose and whether the choice is dangerous
versus simply not the choice the practitioner would make. If the
choice, in fact, is potentially harmful, a collaborative process of
considering alternatives is more likely to produce good choices
than an authoritative, admonitory approach.
Failure to consider the patient as a partner also leads to
violations of confidentiality. Practitioners sometimes assume
that they are the primary arbiters of what information to share
with parents, other clinicians, and other agencies. In fact, in
most circumstances that do not involve the safety of patients
or others, the patient should be the arbiter of what information
is shared with whom. For example, in supported employment,
the patients always determine whether to disclose information
about their illnesses to employers.
R
eferences
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AWorking Life for People with Severe Mental Illness.
New
York: Oxford University Press; 2003.
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Psychiatric rehabilitation practitioner perceptions of frequency and importance
of performance domain scales.
Psychiatr Rehabil J
. 2014;37(1):24–30.
Drake RE, Bellack AS. Psychiatric rehabilitation. In: Sadock BJ, Sadock VA, eds.
Kaplan & Sadock’s Comprehensive Textbook of Psychiatry.
8
th
ed. Vol. 1. Phila-
delphia: Lippincott Williams & Wilkins; 2005:1476.
Ganju V. Implementation of evidence-based practices in state mental health
systems: Implications for research and effectiveness studies.
Schizophr Bull.
2003;29:125–131.
Moran GS, Nemec PB. Walking on the sunny side: What positive psychology
can contribute to psychiatric rehabilitation concepts and practice.
Psychiatric
Rehab J.
2013;36(3):202–208.
Mueser KT, Noordsy DL, Drake RE, Fox L.
Integrated Treatment for Dual Dis-
orders: Effective Intervention for Severe Mental Illness and Substance Abuse.
NewYork: Guilford; 2003.
Rudnick A, Eastwood D. Psychiatric rehabilitation education for physicians.
Psy-
chiatric Rehab J.
2013;36(2):126–127.
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nia.
Schizophr Bull.
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▲▲
28.13 Combined
Psychotherapy and
Pharmacotherapy
The use of psychotropic drugs in combination with psychother-
apy has become widespread. In fact, it has become the standard
of care for many patients seen by psychiatrists. In this therapeu-
tic approach, psychotherapy is augmented by the use of pharma-
cological agents. It should not be a system in which the therapist
meets with the patient on an occasional or irregular basis to
monitor the effects of medication or to make notations on a rat-
ing scale to assess progress or side effects; rather, it should be
a system in which both therapies are integrated and synergistic.
In many cases, it has been demonstrated that the results of com-
bined therapy are superior to either type of therapy used alone.
The term
pharmacotherapy-oriented psychotherapy
is used by
some practitioners to refer to the combined approach. The meth-
ods of psychotherapy used can vary immensely, and all can be
combined with pharmacotherapy when indicated.
Indications for Combined Therapy
A major indication for using medication when conducting
psychotherapy, particularly for those patients with major men-
tal disorders such as schizophrenia or bipolar disorder, is that
psychotropics reduce anxiety and hostility. This improves the
patient’s capacity to communicate and to participate in the psy-
chotherapeutic process. Another indication for combined ther-
apy is to relieve distress when the signs and the symptoms of the
patient’s disorder are so prominent that they require more rapid
amelioration than psychotherapy alone may be able to offer. In
addition, each technique may facilitate the other; psychotherapy
may enable the patient to accept a much needed pharmacologi-
cal agent, and the psychoactive drug may enable the patient to
overcome resistance to entering or continuing psychotherapy
(Table 28.13-1).
The reduction of symptoms, especially anxiety, does not
decrease the patient’s motivation for psychoanalysis or other
insight-oriented psychotherapy. In practice, drug-induced symp-
tom reduction improves communication and motivation. All
therapies have a cognitive base, and anxiety generally interferes
with the patient’s ability to gain cognitive understanding of the
illness. Drugs that decrease anxiety facilitate cognitive under-
standing. They can improve attention, concentration, memory,
and learning in patients who suffer from anxiety disorders.
Number of Treating Clinicians
Any number of clinicians can be involved in treatment of a psy-
chiatric disorder. In
one-person therapy,
the psychiatrist provides
individual psychotherapy and medication treatment. Multiper-
son therapy is a form of treatment in which one therapist (who
may be a psychiatrist, psychologist, or a social worker) conducts
psychotherapy while the other therapist (always a psychiatrist)
prescribes medications. Other therapists may oversee marriage
or family therapy or group therapy. The terms
cotherapy
or
tri-
angular therapy
are sometimes used to describe permutations of
multiperson therapy.
Communication Among Therapists
Whenever more than one clinician is involved in treatment, there
should be regular exchanges of information. Some patients split
the transference between the two; one therapist may be seen as
giving and nurturing, and the other may be seen as withhold-
ing and aloof. Similarly, countertransference issues, such as one
therapist’s identifying with the patient’s idealized or devalued
image of the other therapist, can interfere with therapy. Those
issues must be worked out, and the cotherapists must be com-
patible and respectful of each other’s orientation, so that the
therapy program can succeed.
Table 28.13-1
Benefits of Combined Therapy
Improved medication compliance
Better monitoring of clinical status
Decreased number and length of hospitalizations
Decreased risk of relapse
Improved social and occupational functioning
